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Facing Up Is an Act of Dignity: Lessons in Elegance Addressed to the Polemicists of the First Human Face Transplant

2007; Lippincott Williams & Wilkins; Volume: 120; Issue: 3 Linguagem: Inglês

10.1097/01.prs.0000271097.22789.79

1529-4242

Beno t Lengel, Sylvie Testelin, Sophie Cremades, Bernard Devauchelle,

Biomedical Ethics and Regulation

“The spirit of excellence is to take care more than others think is wise, to risk more than others think is safe, to dream more than others think is real, and to expect more than others think is possible. Elegance is an art of living in the spirit of excellence, seeking to create more passion, grace, and beauty than others think is practical.” Concluding a conference entitled “Microsurgery and Elegance” some years ago, we asked ourselves whether face transplants, under discussion at the time, constituted the ultimate accomplishment in surgical elegance or, on the contrary, a total lack of it. Even today, although we are best placed to answer this question, it is no easy task for us, in all humility, to provide a final conclusion to this issue. One thing, however, is certain: reconstructive surgery cannot exist without some component of elegance. Likewise, the scientific spirit from which it arises, the gestures it requires, the way in which it carries them through, the pertinent nature of its indications, and the ethics of its accomplishment with regard to respect of the patient, cannot escape this imperious requirement. Moreover, no exception to these rules of excellence should exist when, breaking down the barriers of what is allegedly possible, reconstructive surgery continues to explore new fields in an unknown universe with the same desire for elegance. Everyone here should be aware that it was this noble virtue that guided the medical teams who performed the first human face transplant in Amiens, France, on November 27, 2005. In relation to transplants, of whatever type, French law enforces respect for the anonymity not only of the donor–-obviously–-but also of the recipient. In a surgical first, it could be surmised that due observance of this regulation can be difficult with regard to the recipient when the media start to become involved. Very quickly indeed, and unbeknown to the medical teams, the name of the patient appeared in mainstream newspapers. This does not, however, mean that the scientific authors of surgical firsts depart from observation of the rules and do not respect the anonymity of patients in their scientific communications or publications. This was, in our specific case, a formal duty of obligation that was never transgressed. Revealing the name of a donor and the medical circumstances before his or her brain death is a much more serious transgression, strictly forbidden by law, that is liable to be pursued in court. Even though certain British tabloids, relayed in turn by other newspapers, infringed on this law by publishing such information, also unknown to the medical team at the time of operation, it does not entitle other members of the medical profession to relay this information in an editorial published by a scientific journal,1 the latter one acting ipso facto illegally too. Therefore, let us first remind everyone concerned of our deontological duty of reserve and call on everyone to have the elegance to be able to respect anonymity. Why should the presumed fragility of patients condemn them to be deprived of the best therapeutic management, when medical ethics rule that we should care for our fellow human beings in accordance with the rules of good practice, using the most up-to-date tools available to science? Would “merit” then become an issue in patients’ entitlement to benefit from treatment? An affirmative answer would lock us into the most damnable form of ostracism, diametrically opposed to our obligations as health care providers. Moreover, from a strictly philosophical perspective induced by our Hellenistic culture, would someone’s suicide constitute a sign of weakness for certain people, while for others, within a different cultural context, it is a sign of strength and wisdom? By taking the Hippocratic oath, have we not all solemnly undertaken not to allow any philosophical considerations or value judgments with respect to others to come between us and the inalienable right of our patients to receive the best possible treatment our art can provide, regardless of what or who they are? Remaining true to these oaths and retaining respect for pain and the life choices of others is not merely a matter of honor. It also represents elegance of thought in human terms. The patient who received the first face allograft, whose real circumstances before she was bitten by her dog actually remain unknown to anyone (Figs. 1 through 3), was attended to over a period of 6 months by three different teams of psychiatrists. All the experts consulted concluded unanimously that she was in a position to understand the issues of the innovative treatment that was being proposed to her and, subsequently, to deal with the constraints of the adjuvant treatment to which she was to be subjected. Every day that goes by confirms that their analysis was well founded. The surgeons had undertaken, regardless of the issues at stake, to respect the opinion of their colleagues, since there is a definite virtue of elegance in this humility to be able to delegate to, and moreover to respect the views of, those who are much more competent than oneself in a given field.Fig. 1.: Preoperative view of the patient.Fig. 2.: Two-month postoperative view.Fig. 3.: One-year postoperative view. Photograph courtesy of CHU Amiens, November 21, 2006.Would selling one’s image be reprehensible for the beneficiary of a medical first and, a contrario, perfectly acceptable or even encouraged and arranged for a sporting personality, an actor, or an artist in the public eye? Would people then dare to go so far as to say that the patient voluntarily mutilated her own face to be tomorrow’s media star of a surgical first? Likewise, it was also written that a financial contract had been drawn up to the benefit of our patient long before surgery took place, to better convince her, taking advantage of her supposed weakness of spirit, that the operation was obviously indicated in her situation. Stating this would, first and foremost, constitute a severe infringement of a patient’s moral integrity, on the basis of a simple process of abusive and malicious intentions. However, it is also a particularly basic error of ignorance, as it flouts French law, which obliged our patient to read over and sign the consent form anew in the presence of her psychiatrist, on the very eve of her transplant, when she was informed of her potentially imminent operation. In relation to surreptitious claims that the members of the medical team might, at some point, have derived financial benefits from their involvement, short on arguments and in defiance of all collegiality, this is simply heaping discredit on others, gratuitous libel, and claiming that the success of others is suspect a priori. In fact, the others, above all, did all they could to preserve the rights of the patient and were wary of appearing, directly or indirectly, in any contract which, due to an obvious conflict of interests, would beyond any shadow of a doubt have discredited the scientific value of their actions. In a world in which personal profit constitutes, in quasi-consensual fashion, the principal motivation of many human adventures, and in which the medical community, alas, does not always manage to escape this commercial trend, refusing to accept such compromise, with gentleness and disinterest, was thus also an elegant gesture. For anyone who tried to find out the extent of the scientific preparations for the first face transplant, beyond the often erroneous or partial information revealed by the audiovisual media, there can be no doubt that a serious approach and intellectual honesty were the surgeons’ watchwords as they progressed. Conscientious journalists in the mainstream press made no mistake here2: they realized, in fact, the degree of detail deployed during both the implementation and the final performance of the operation as well as the concern for perfection, as evident from its multidisciplinary organization, gathering around the patient the best specialists in a wide range of scientific domains. The scientific community also clearly understood this point and invited all members of the team to speak at the most prestigious tribunes3 and published their early results in the best scientific journals.4 The authors’ contribution was, in fact, hailed in the name of their peers by Joseph E. Murray, the 1990 Nobel Prize winner in physiology or medicine, as follows: “French doctors did not bypass ethical rules or standard procedures of reconstructive surgery, as some critics have charged… Furthermore, the French team achieved a superb reconstructive result…”5 At the Sixth International Symposium on Composite Tissue Allotransplantation, held in Tucson, Arizona, in January of 2006, when they first presented their preliminary results to the international scientific community, the authors were indeed keen to pay personal tribute to Joe Murray and dedicated the success of the first face transplant to him. In doing so, they wished to point out that this feat, mainly due to advances in knowledge and techniques in the field of immunology, was no more than the outcome, in their hands, of the dream of this courageous pioneer. They sought, in all humility, to make the elegant gesture of returning the dream, now made reality, to the first person who had dared to believe that this dream, after a long period of hope and patient labor, could one day come true. Scientific progress, in fact, belongs to no one, not even those who have achieved it. If history honors such people by associating their names with novel discoveries that subsequently prove useful to all their colleagues, and thus to all mankind, those who attempt to explore new horizons are aware that, amid the emotion and indignation occasionally aroused by revelations concerning the unknown, controversy and adversity are trials they must face with distance and dignity. Galileo, Copernicus, Harvey, Darwin, Murray himself, and many others all met with this painful experience. Accepting this reality of fate, but refusing to let others inundate you with opprobrium, is an elegant attitude that history rewards justly, remembering the humble who, in a nonviolent fashion, have been able to keep quiet and persevere in their quest for progress, whereas it reserves a stern and sometimes satirical judgment for those who yielded to the heat of the moment, expressed their feelings without measure, and injudiciously opposed the path toward progress.6 The same holds for those whose sole ambition appears to be, as part of a singular bidding process, the desire to appropriate the work of others in the hall of fame.7,8 “To treat is to experiment,”9 wrote our Flemish predecessor Andreas Vesalius, in the introduction to his Fabrica, now universally held to be the founding tome of modern medical thought. Almost five centuries later, evidence-based medicine continues, with good reason, to subordinate the exercise of the art of treating to the practice of rigorous observation of clinical facts and to the necessity of supplying tangible proof of the beneficial effects of each treatment proposed. The conception of a medical first as a truly noble experience is therefore an absolute scientific duty. It is for this reason that everyone involved in the first face allografting procedure strove, from the outset, to collate tirelessly, in a prospective and meticulous manner, any observation that could prove useful at a later stage. Beyond the courage and audacity required by the initial act of incision, this wish to update, step by step, the catalogue of its immediate and late effects, whether positive or negative, is a brave and daring desire that bares its defenseless self to the justice of time. It is also an act of elegance, since, going beyond any desire for self-promotion at the risk of facing uncertainty, its only ambition is to submit the results to the whole medical community. These results, which have already been published,4 or will be published later in various journals, will provide the only reply, beyond this editorial, which we wish to bring in all serenity to our detractors. Modern surgery originated and received its letters of nobility at a time when elegance recommended that gentlemen settle affronts to their honor in a meadow, in the mist of early dawn. Although they are the offended party and are therefore entitled to choose their weapons, the authors feel that these days of the past, glorious though they may have been, are definitely over. They thus preferred to take up pen and paper and let ink flow, rather than symbolically lend themselves to the spilling of blood in a battle field or in a court of law. Each individual can indeed decide after completion of this lecture that the elegance which they invoke places them above the defamatory reports on their work. However, the authors also felt that it was their duty, in line with elegance and respect for readers, to face the controversy, as they had initially dealt with the reality in the operating theater. This is why they chose, within the pages where their honesty and uprightness had been publicly questioned,1 to restore both the historical and scientific truth: the first human face transplantation was not born of hazard and venture but of necessity.10 In the hearts and hands of all those who carried out this procedure with the best intentions, this step forward in the history of reconstructive surgery has imposed itself as a medical duty of pursuing excellence and as a human act of dignity.